Pet insurance

How we resolve pet insurance complaints

• A policy condition or exclusion applies

  If your customer has shown they have a valid claim under their policy, you should pay the claim unless you can prove that a policy condition or exclusion applies.

  Most pet insurance policies have exclusions and limitations. If we find any that are significant or unusual, we’ll look at what you told the customer when they took out the policy. We’ll take into account any medical evidence provided by vets – in particular, clinical notes and written submissions. 

  You might refer to the meaning of certain key words in the policy, for example, ‘condition’ or ‘treatment’. If you’ve defined a term differently from its everyday meaning, we’ll look at how you did this, for example, by using a key words glossary. We’ll consider how you explained this to the customer.

  If the meaning was open to interpretation, we may decide that you’ve unfairly applied the exclusion or limitation. For example, an examination or consultation isn’t generally considered to be a ‘treatment’. So, we’d look at how the policy defines ‘treatment’ and whether you brought this to the customer’s attention.

• Adding policy exclusions mid-term

  The remedy to turn back the clock and apply an exclusion retrospectively is set out in the Consumer Insurance (Disclosure and Representations) Act 2012 (or CIDRA). CIDRA sets a duty on a consumer to take reasonable care not to make a misrepresentation when a contract is entered into or varied.

  For a remedy to be available to you under CIDRA, you’d need to show that:

  • you asked your customer a clear and specific question which they failed to answer correctly or with reasonable care resulting in a misrepresentation, and
  • had they done so, you would’ve done something differently like offered the policy on different terms or not at all, making the misrepresentation a qualifying one. We’d need to see your underwriting criteria to support this.

  Read more on our approach to misrepresentation and non-disclosure

• Pre-existing conditions

  Most policies don’t cover pre-existing conditions or a condition that appears in the first 14 days of the policy. We’d expect you to have mentioned this to the customer at the point of sale and within the insurance product information document (IPID). We wouldn’t agree that it was enough to tell the customer to read the policy document.

  If you refuse a claim on the grounds of a pre-existing condition, there are two main things we’d consider:

  • is it the same, or a related, condition?
  • did the customer know about it?

  Sometimes the signs of condition are apparent before the policy starts, but the condition itself doesn’t manifest until after the policy is in place. In these situations, you need to show it is the same condition, or that they’re related or have the same underlying cause.

  We’ll also consider what the customer knew when they took out the policy and whether they could have reasonably known there was something wrong. If not, we wouldn’t consider it fair to refuse their claim, particularly if the vet told them there wasn’t a problem.

• The pet is aggressive or has shown signs of aggression

  If you don’t insure aggressive dogs or particular breeds, we’d expect this to have been brought to a customer’s attention when they took out the policy so that they could decide whether it’s a suitable policy for them. 

  If you’ve declined a claim relying on an exclusion for aggressive dogs, we’ll review the specific wording of the policy exclusion and the available evidence. If the dog has clearly been aggressive and attacked someone, it’s likely we’ll say it’s fair to rely on the exclusion. 

  But if the only evidence of aggression is from times when the animal was at the vets or undergoing a veterinary procedure – that is, when it was in pain or being examined – we’re unlikely to say that means the dog is genuinely aggressive.

• The terms and conditions of a lifetime policy have changed

  If you describe a policy as ‘lifelong’ or ‘lifetime’, you won’t normally be able to change the policy’s basic cover.

  If an underwriter withdraws cover, and the customer isn’t offered an option to renew, they will effectively have lost their lifetime cover. And it’s unlikely a new insurer will cover any existing conditions.

  If the customer takes out a new lifetime policy with another insurer, we may tell you to provide ongoing cover for any existing conditions that aren’t covered by the new policy.

  If the customer is offered a new policy with a different underwriter, it’s likely we’ll say the new policy should reflect the old policy’s terms and conditions. This should include any conditions that would have been covered by that policy.

  We may award compensation for distress and inconvenience in both those scenarios.

  You can make changes to a lifetime policy at renewal, but if these significantly change the customer’s original cover, we’re likely to uphold the complaint.

• The price of the policy has significantly increased

  A customer may complain if you’ve significantly increased their premium when they renewed their policy.

  It's not for us to tell you what price to charge for covering a particular risk. But we can look at whether you set the premium fairly. We’ll consider:

  • underwriting criteria 
  • the factors which caused the price to increase
  • whether you gave the customer enough information about any future price rises before they took out the policy, or made it clear that future price rises could be substantial, particularly as the pet gets older.

  If we think you increased the premium to profit unfairly from a particular customer or group – or to put them off renewing – we’re likely to uphold the complaint.

  We’re also aware of concerns about the rising costs of policies that include a continuation benefit or ‘lifetime’ element. Any type of continuous cover can also have benefits that would be lost if the policyholder changed provider. So, to enable customers to make informed decisions, it’s important to give the customer enough information about any future price rises before they out take the policy.

• Time limits on cover for treatment

  Some policies may limit cover for a particular condition to a specific time limit, for example, a 12-month period. Your customer may be unhappy about when that time limit starts. 

  We’ll look at what the policy says, but we’d normally say it’s fair for an insurer to start the 12 months from when the customer could have made a claim for treatment. This is usually when a vet recommends some sort of investigation or treatment for clinical signs of a condition. 

  It’s rare for a condition to appear on the exact date that a policy starts. So the policyholder will normally have to renew the policy to be able to claim for the full 12 months. And we’d expect this to have been made clear to the policyholder.

  We wouldn’t usually ask you to pay for claims if the policy had ended and the customer was no longer paying the premiums. But if you didn’t highlight this time limit, we’ll consider whether your customer would have continued with the policy.

  When settling a claim, you should let your customer know that any future claims for the same condition won’t be covered after the time limit has passed. This information will help them decide whether they want to renew the policy .

• A bilateral condition

  Where a condition has previously affected one side of an animal and your customer then claims for the other side, you may have declined these claims because:

  • you consider this to be a pre-existing condition
  • the 12-month time limit began when the problem occurred on the first side and has now expired.

  We’ll look at the available evidence, such as the vet’s opinion and the animal’s medical history, to decide if the two events were directly connected.

  As with our approach to pre-existing conditions, we’ll consider whether:

  • this is the same condition affecting the other side of the animal, whether they’re related or have the same underlying cause,
  • the customer knew the second side was likely to become affected by the same condition later, given what the vet told them at the time and how much time has passed. 

  We’re likely to agree with your decision to reject the claim, if:

  • the evidence suggests the underlying issue is the same – such as a disease process, and
  • your customer was aware of symptoms for some time.

  We might think it’s fair for you to treat it as a separate issue, if:

  • a significant period of time has passed since the initial condition, and
  • the vet notes show that they examined the the other side when the problem was first presented and didn’t find anything wrong.

• The policy doesn’t cover dental treatment

  If you denied a claim because your customer's policy didn't include dental treatment, we’ll consider whether the policy term:

  • is clear, fair, and not misleading, and
  • has been applied fairly taking into account the individual circumstances of the claim.

  We’ll think carefully about whether it’s fair to apply the exclusion for dental treatment if it was necessary as part of the treatment of something else. This might be, for example, where a vet’s had to remove a tooth in order to treat a tumour.

  We often see claims where an animal has received treatment for a condition which has presented itself in the animal’s mouth, like a lump. Customers might complain that had the lump presented itself anywhere else on the body, then their claim would have been accepted so the exclusion shouldn’t apply. 

  In cases like this, we’ll consider the medical evidence. If there’s been a diagnosis and the condition is one which would only present in the jaw or gums, then we’ll usually say you can rely on the exclusion. But if the lump could have appeared anywhere on the animal’s body, we might think it’s unfair for you to rely on the exclusion.

• Euthanasia on equine policies

  These claims are usually only covered if the decision is in line with the BEVA guidelines on best practice for considering euthanasia on humane grounds.

  Customers sometimes complain that a horse was put down for humane reasons. But you didn’t cover the claim because the euthanasia didn’t comply with the BEVA guidelines.

  We’ll look at the policy wording and check that the procedure was carried out in line with the guidelines. For example, this may be where:

  • the condition was so severe, the horse had to be put down immediately
  • the insurer was contacted, or another vet was asked to give a second opinion.

  Some equine policies specify that the BEVA guidelines must be complied with for a claim to be paid. Other policies may use different wording, for example, that a claim is only valid if there’s no other treatment option and euthanasia is ‘imperative’, but doesn’t mention BEVA.

  In both these cases, if evidence shows that no alternative treatment was available and it was necessary to euthanise the horse, we’re likely to uphold the complaint.

• Reasonable care

  We’ll look at how the policy defines ‘reasonable care’. If there’s no definition, we’ll use the test set out in the case Sofi verses Prudential Assurance (1993). This says that if an insurer declines a claim on the basis the consumer didn't take reasonable care, they must show the consumer acted in a reckless way.

  We’ll consider things like:

  • the customer’s actions – where they were when the pet escaped and how long they took to realise their pet was missing
  • where the pet was before the escape, for example, in the customer’s house or garden, or near a busy road
  • how easy was it for the pet to escape, whether the area enclosed was or sufficiently supervised
  • details about the pet itself – for example, a young puppy is more likely to escape than an older dog
  • the pet’s past behaviour – whether they have escaped before and this was a foreseeable risk.

  We might consider it unfair for you to decline the claim if we think:

  • the customer has taken reasonable care, or
  • the pet would likely have escaped even if the customer had acted differently. 

• The policy has been mis-sold

  If the complaint is about a mis-sale, we’ll look at:

  • who sold the policy, and
  • whether or not you sold it on an advised basis..

  If you gave advice, you have a responsibility to make sure the policy is suitable for the customer.

  If the customer bought the policy without advice, they should have been given enough information to decide whether the policy was right for them at the point of sale. You must provide information that’s clear, fair, and not misleading, that highlights key benefits and limitations.

• Deductions for policy excesses, co-payments, or policy limits

  An excess and co-payment are significant policy terms and so they should be made clear to your customers in a policy summary or similar document, such as an insurance product information document (IPID). 

  If these aren’t made sufficiently clear at the point of sale or renewal, then we might not think it’s fair to apply them.

  We’d expect you to deduct the excess and co-payment from the claimed amount before applying any policy limits. 

  We don’t think it’s fair to apply the policy limit to the claim first and then take off the excess and co payment afterwards. Otherwise the customer will never benefit from the full cover their policy is meant to provide.